Guidelines Summary
The fourth edition of the guideline on management of major bleeding and coagulopathy following trauma, by the pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma, includes the following [6] :
-
Early imaging (ultrasonography or contrast-enhanced CT) should be used for detection of free fluid in patients with suspected torso trauma.
-
CT assessment should be provided for hemodynamically stable patients.
-
Low initial Hb should be considered an indicator for severe bleeding associated with coagulopathy.
-
Repeated Hb measurements should be used as a laboratory marker for bleeding, as an initial Hb value in the normal range may mask bleeding.
-
Serum lactate and/or base deficit measurements are sensitive tests to estimate and monitor the extent of bleeding and shock.
-
Repeated monitoring of coagulation, using a traditional laboratory determination (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet counts, and fibrinogen) and/or a viscoelastic method, should be provided.
-
Target systolic blood pressure is 80-90 mm Hg until major bleeding has been stopped in the initial phase following trauma without brain injury.
-
In patients with severe traumatic brain injury (TBI) (GCS ≤8), mean arterial pressure ≥80 mm Hg should be maintained.
-
Fluid therapy using isotonic crystalloid solutions should be initiated in the hypotensive patient with bleeding trauma.
-
Excessive use of 0.9 % NaCl solution should be avoided.
-
Hypotonic solutions such as lactated Ringer’s solution should be avoided in patients with severe head trauma.
-
Use of colloids should be restricted due to adverse effects on hemostasis.
-
Target Hb is 7-9 g/dL.
-
In initial management of patients with expected massive haemorrhage, one of the following strategies should be used: Plasma (FFP or pathogen-inactivated plasma) should be provided at a plasma-to-RBC ratio of at least 1:2 as needed, with fibrinogen concentrate and RBC according to Hb level.
-
Tranexamic acid should be administered as early as possible to the trauma patient who is bleeding or is at risk of significant hemorrhage, at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours.
-
Tranexamic acid should be administered to the bleeding patient with trauma within 3 hours after injury.
-
Protocols for treatment of bleeding patients should consider administration of the first dose of tranexamic acid en route to the hospital.
-
If a plasma-based coagulation resuscitation strategy is used, plasma (FFP or pathogen-inactivated plasma) should be administered to maintain PT and APTT < 1.5 times normal control values.
-
Plasma transfusion should be avoided in patients without substantial bleeding.
-
If a concentrate-based strategy is used, treatment with fibrinogen concentrate or cryoprecipitate should be provided if significant bleeding is accompanied by viscoelastic signs of a functional fibrinogen deficit or a plasma fibrinogen level less than 1.5-2.0 g/L.
-
Initial fibrinogen supplementation of 3-4 g is used, which is equivalent to 15-20 single donor units of cryoprecipitate or 3-4 g of fibrinogen concentrate. Repeat doses must be guided by viscoelastic monitoring and laboratory assessment of fibrinogen levels.
-
Platelets should be administered to maintain a platelet count above 50 × 109/L.
-
Platelet count above 100 × 109/L should be maintained in patients with ongoing bleeding and/or TBI.
-
Initial dose is 4-8 single platelet units or 1 apheresis pack.
-
CT scan of a 26-year-old man after a motor vehicle crash shows a significant amount of intra-abdominal bleeding.
